cyberknife technology in ablative radiation...

CyberKnife Technology in

Ablative Radiation Therapy

Jun Yang PhD

Cyberknife Center of Philadelphia

Drexel University

Jan 2017

Objectives

Components and work flow of CyberKnife

Motion management of CyberKnife

Dosimetry characteristics of CyberKnife

New development of CyberKnife

QA of CyberKnife

CyberKnife Components & treatment

Motion management

Dosimetry

Quality Assurance

CyberKnife® Components

DiagnosticX-Ray Source

Image Detectors

Treatment Couch

Linear Accelerator

Robotic Arm

DiagnosticX-Ray Source

Linear Accelerator

330 lbs.

6 MV X-ray

1000 MU/min

Three set collimators

– 5 – 60 mm circular collimators

– 5 – 60 mm dodecagonal (12-sided)

IRIS variable aperture collimators

– 100 x 120 mm MLC

Robot SpecificationsMade by KUKA of Germany

6 axis / joint motion

1,525 kg (w/Linac)

210 kg payload

208 VAC, 3 Phase (PDU)

0-45 ºC operating range

<75% Relative humidity

13 ft x 16 ft operating

envelope (3 m reach)

0.12 mm repeatability

5° Treatment Couch (Axum)

Accommodates up to 159

kg patient (350 lbs)

Motorized control with 5

degrees of freedom Inferior-superior

Anterior-posterior

Right - left

Roll

Pitch

Image Tracking System

2 diagnostic X-Ray sources

+ 2 ASi image detectors

(cameras)

Patient imaged at 45°orthogonal angles

Real-time, live images

compared against DRRs

generated from CT

During treatment, Robot

adjusts position based on

the comparison

Dx X-Ray Sources

Amorphous Silicon Detectors

Development of CyberKnifeG4 M6

Fixed Cones

IRIS MLC

InCise MLC:

* 41 leaf pairs

* 2.5 mm leaf thickness @ 800 mm* 120 mm x 100 mm field size

* 90.0 mm leaf height* 0.5 mm leaf position accuracy

* 0.4 mm reproducibility

* Transmission: <0.3% avg(<0.5% max)

* Full leaf inter-digitation* Full leaf over-travel* Single Focus MLC

Cyberknife G4 -> M6

Digital Platform

Different Robot position

MLC -> IMRT capable

SBRT: faster, slightly better SBRT plan

IMRT: comparable with Linac based

SBRT Plan Comparison

MLC Fixed Cones

CyberKnife Components & treatment

Motion management

Dosimetry

Quality Assurance

Case Specific Tracking Modalities

Skull Tracking ----- Brain tumor

X-site (spine) Tracking ----- Spine tumor

Fiducial Tracking ----- Soft tissue

Synchrony Tracking ----- Moving Soft tissue

X-sight Lung ---- Moving visible lung tumor

Lung Optimization Treatment --- a full set of

tracking for lung tumor without fiducial

Tracking Methodology

DRR (Digitally Reconstructed Radiographs)

library used as references.

X-ray images acquired in real time

Registration between 2 DRR and X-ray images

The patient’s rigid transformation calculated

Skull Tracking and Correction

Accuracy - Overall translation error ~ 0.5mm, rotation error ~ 0.5 degree.

Spinal Tracking and Correction

Special application: Bony Structures

Fiducial Tracking and Correction

Special application: Surgical Clips

Tumor Respiratory Motion Consideration

Breath Hold Gating

Synchrony Motion Tracking and

real-time Correction

Synchrony Motion Tracking and

real-time Correction

Xsight-Lung Tracking and real-

time Correction

Special application: Sternum, Metal Stent, Large Calcification

Lung tumor tracking without

fiducialsXsight® Lung TrackingRadiosurgical margins

Maximum similarity

Similarity Measure

Lung tumor tracking without fiducials

Xsight® Lung TrackingRadiosurgical margins

View A View B

View A View B

View A

Lung tumor tracking without fiducials

1-View Tracking*ITV expansion in non-tracked direction

Xsight® Lung TrackingRadiosurgical margins

View B

Lung tumor tracking without fiducials

0-View Tracking*ITV expansion in all directions

1-View Tracking*ITV expansion in non-tracked direction

Xsight® Lung TrackingRadiosurgical margins

Targeting AccuracyMechanical accuracy

– 0.12 mm (Kuka Specification 2004)1

Targeting accuracy for targets not affected by respiration

– 0.95 mm (Xsight® Specification)

– 0.52 +/- 0.22 mm (Muacevic et. Al. 2006)2

– 0.49 +/- 0.22 mm (Ho et. al. 2008)3

– 0.4 +- 0.2 mm (Antypas and Pantelis 2008)4

– 0.47 +- 0.24 mm (Drexler & Furweger 2009)5

Targeting accuracy for targets that move with respiration

– 1.5 mm (Synchrony® Respiratory Tracking System specification)

– 0.70 +/- 0.33 mm (Dieterich et. Al. 2004)6

– 0.47 +- 0.24 mm (Drexler and Furweger 2009)5

1 Kuka KR240-2 Specification 04.2004.05

2 Muacevic A, et. al. Technical description, phantom accuracy and clinical feasibility for fiducial-free frameless real-time image-guided spinal

radiosurgery. J Neurosurg Spine. 2006 Oct;5(4):303-12.

3 Ho AK, et al. A study of the accuracy of Cyberknife spinal radiosurgery using skeletal structure tracking. Neurosurgery 2007;60:147-156.

4 Antypas C and Pantelis E. Performance evaluation of a CyberKnife G4 image-guided robotic stereotactic radiosurgery system. Phys Med

Biol 2008;53:4697-4718

5 Drexler and Furweger. Quality assurance of a robotic, image guided radiosurgery system. WC 2009, IFMBE Proceedings 25/I, 492-495, 2009

6 Dieterich S, et. al. The CyberKnife Synchrony Respiratory Tracking System: Evaluation of Systematic Targeting Uncertainty. White paper 2004.

CyberKnife Components & treatment

Motion management

Dosimetry

Quality Assurance

Dosimetry: various beam arrangements

Isocentric

-- single shot

-- multiple shots

Non-isocentric

-- Conformal

Cyberknife – 80 Beam SRS

7 Beam IMRT “Tomo”, single Plane RT

Non-coplanar beams

Applications– Plan Evaluation

Conformal Non-isocentric Plan Fast Fall-off Isocentric Plan

40Gy340Gy3

CyberKnife Components & treatment

Motion management

Dosimetry

Quality Assurance

Quality Assurance

End 2 End test

BB test

AQA

Beam analysis

Plan dose verification

Image system test

Daily, Monthly, Quarterly and Annually QA

QA guidelines: TG 135: Quality

assurance for robotic radiosurgery

QA guidelines: AAPM-RSS Medical Physics

Practice Guideline 9.a. for SRS – SBRT(Draft)

Morning QA - Output

Morning

QA – AQA

W-L test

Monthly QA- Ouput/Energy

Monthly QA – Symmetry and

Flatness/ Laser Alignment

Monthly QA – IRIS Collimator Field Sizes

Monthly QA – E2E

Monthly QA – Imaging Center

Which of these following tracking modalities used in the

lung cancer treatment can accommodate expiratory

motion?

1 Xsight-lung tracking

2 Spine tracking

3 Synchrony Tracking (using fiducial)

4 Lung Optimization Treatment

A: 1, B: 1, 2, 3 C: 1, 3, 4 D: 1, 2, 3, 4

Ans: C only the spine tracking in the list uses bony

information of spinal skeleton as tracking landmark.

Ref: TG135 “Report of AAPM TG 135: Quality assurance for robotic

radiosurgery”

What is not true for Cyberknife

a. Allows multiple non-coplanar beams

b. Allows single isocentric or non-isocentric

shots, but not multiple isocentric shots

c. Fully optimized with inverse planning

d. Allows motion correction during treatment

delivery

Answer: B

Ref:Jun Yang, John Lamond, Jing Feng, Xiaodong Wu, Rachelle Lanciano, and

Luther W. Brady “CyberKnife System” Chapter of S Lo, MD etc, “Stereotactic

Body Radiation Therapy” Springer Press, 2012, pp 37-52

Thanks